Cross-Model Office Hours Session Primary Care First, Direct - - PowerPoint PPT Presentation
Cross-Model Office Hours Session Primary Care First, Direct Contracting, and Kidney Care Choices December 19, 2019 Center for Medicare and Medicaid Innovation Centers for Medicare & Medicaid Services (CMS) 1 Presentation Overview
December 19, 2019
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a) Primary Care First b) Direct Contracting c) Kidney Care Choices d) All three models and their differences e) Unsure
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Primary Care First Goals Primary Care First Overview 1 2
To reduce Medicare spending by preventing avoidable inpatient hospital admissions To improve quality
care and access to care for all beneficiaries, particularly those with complex chronic conditions and serious illness 5-year alternative payment model Offers greater flexibility, increased transparency, and performance-based payments to participants Payment options for practices that specialize in patients with complex chronic conditions and high need, seriously ill populations Fosters multi-payer alignment to provide practices with resources and incentives to enhance care for all patients, regardless of insurer Center for Medicare & Medicaid Innovation Primary Care First
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Focuses on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burden and performance- based payments. Allows practices to participate in both the PCF- General and the SIP components of Primary Care First.
The three Primary Care First payment model options accommodate for a continuum of providers that specialize in care for different patient populations. Option 1
PCF-General Component
Option 2
SIP Component Promotes care for high-need, seriously ill population (SIP) beneficiaries who lack a primary care practitioner and/or effective care coordination.
Option 3
Both PCF-General and SIP Components Center for Medicare & Medicaid Innovation Primary Care First
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In 2021, Primary Care First will include 26 diverse regions:
Current CPC+ Track 1 and 2 regions New regions added in Primary Care First Practices that are currently not participating in CPC+ but are located in a CPC+ region may be eligible to apply. Current CPC+ practices may participate in Primary Care First beginning in 2022. Center for Medicare & Medicaid Innovation Primary Care First
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The following criteria apply to practices who seek to participate in the general Primary Care First payment model or in both the general and SIP payment models. In the application, you will need to attest that you meet the following criteria:
Include primary care practitioners (MD, DO, CNS, NP, PA) in good standing with CMS Provide health services to a minimum of 125 attributed Medicare beneficiaries Have primary care services account for at least 70% of the practices’ collective billing
based on revenue
Demonstrate experience with value-based payment arrangements Meet technology standards for electronic medical records and data exchange Provide a set of advanced primary care delivery capabilities
Note: Practices participating in the SIP option will be subject to requirements discussed later in this presentation.
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The Total Primary Care Payment is a hybrid payment that incentivizes advanced primary care while compensating practices that care for higher-risk patients for the increased level of care these patients typically need.
Payment for service in or outside the office, adjusted for practices caring for higher risk
patients within a practice.
Population-Based Payment Flat Primary Care Visit Fee
Payment for in-person treatment that reduces billing and revenue cycle burden.
per face-to-face encounter
Payment amount does n
include c
geographic adjustment
These payments allow practices to:
Easily predict payments for face-to-face care Spend less time on billing and coding and more time with patients
Practice Risk Group
Group 1: Average Hierarchical Condition Category (HCC) <1.2 Group 2: Average HCC 1.2-1.5 $28 $45 Group 3: Average HCC 1.5-2.0 $100 Group 4: Average HCC >2.0 $175
Payment
(per beneficiary per month*)
Payment will be reduced through calculating a “leakage adjustment” if beneficiaries seek primary care services outside the practice.
* PBPM = Per Beneficiary Per Month
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Did the practice meet the annual quality benchmarks (i.e., Quality Gateway)?
0% or -10%
No
Performance Based Adjustment Is practice performance above the 50th percentile of the national Acute Hospital Utilization (AHU) benchmark?
Yes
Note: this begins in year 2, based on year 1 performance*
For year 2, PBA will be 0% or
years 3-5, PBA is automatically
Yes No
Top 75% of PCF practices on AHU?
No Yes
Adjustment
0%
Adjustment
AHU Measure Performance TPCP Adjustment Top 10% of regional practices 34% 11-20% of regional practices 27% 21-30% of regional practices 20% 31-40% of regional practices 13% 41-50% of regional practices 6.5% 51-75% of regional practices 0% Bottom 25% of regional practices
Regional Adjustment
1
Continuous Improvement Adjustment
Does the practice’s AHU performance compared to their performance last year achieve the continuous improvement target?
2
Yes
0%
Adjustment
* Performance-based adjustments in year 1 are based on performance on the AHU measure only and does not follow the above process.
No
AHU Measure Performance TPCP Adjustment Top 10% of regional practices 16% 11-20% of regional practices 13% 21-30% of regional practices 10% 31-40% of regional practices 7% 41-50% of regional practices 3.5% 51-75% of regional practices 3.5% Bottom 25% of regional practices 3.5%
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Goals of SIP Model Option
Offer a transitional high touch, intensive intervention to help stabilize SIP patients, promote relief from symptoms, pain, and stress, develop a care plan, and transition them to a provider who can take responsibility for their longer-term care needs Provide participating practices with additional financial resources to proactively engage SIP patients, address their intensive care needs, and help them achieve clinical stabilization and transition Transform high-need patient care into a replicable population-health initiative that is patient-centered and supports long-term chronic care management
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CMS Identifies SIP Patients: CMS uses claims data to identify beneficiaries in
designated service areas. Practice seeks to make contact as soon as possible with interested SIP patients.
Practice Engages New SIP Patients: Practice administers a face to face visit with patient
within 60 days of identification.
Practice Administers Care: Practice provides treatment and care coordination for attributed
SIP patients. Practice receives payment adjustments based on quality of care.
Patient Transitioned Out of SIP Payment Model Option: Practice transitions patient to
long-term care setting or other eligible provider. Practice no longer receives SIP payment for transitioned patients. Center for Medicare & Medicaid Innovation Primary Care First
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Monthly professional population-based payment Quality bonus One time payment for first visit Flat visit fee
SIP Payments
$325
(not geographically adjusted; inclusive of flat visit fee)
$275 PBPM* base rate minus a $50 withhold†
(both geographically adjusted)
$50 PBPM* base rate
(geographically adjusted)
$40.82 base rate per face-to-face encounter
(begins after attribution; geographically adjusted)
By default, SIP practices will receive up to 12 months‡ of SIP payments per SIP patient, unless the beneficiary is transitioned or de-attributed sooner. Additional payments beyond 12 months may be allowed as appropriate on a per patient basis subject to CMS approval and practice eligibility.
*PBPM = per beneficiary per month † SIP practices will have the opportunity to earn back the $50 PBPM base rate withhold from their SIP PBPM payment. ‡ Exceptions may apply. Please see the Request For Applications (RFA) for more details.
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Please complete your Primary Care First practice application by January 22, 2020. Fall 2019
Practice applications
Payer statement of interest posted
Winter 2020
Practice applications due; Payer solicitation
Spring 2020
Practices and payers selected
Summer/Fall 2020
Onboarding
Participants
January 2021
Model launch; Payment changes begins
Practice application and payer statement of interest submission period begins Practice and payer selection period
Interested practices should review the Request for Applications (RFA) and can access the Application Portal to complete an application. Center for Medicare & Medicaid Innovation Primary Care First
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Goal
Transform risk-sharing arrangements Empower and engage beneficiaries Reduce provider burden
How CMS expects that Direct Contracting will achieve these goals
chronically ill populations
incentives
participate
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Model and the updated Medicare Shared Savings Program ENHANCED Track, are part of the CMS strategy to use the redesign of primary care to drive broader delivery system reform to improve health and reduce costs.
Model and innovations from Medicare Advantage and private sector risk sharing arrangements.
Lower risk Higher risk Primary Care First Medicare Shared Savings ENHANCED Track Direct Contracting
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Professional
Participants and Preferred Providers defined at the TIN/NPI level
savings/shared losses with CMS
Capitation (PCC) equal to 7% of total cost of care for enhanced primary care services
Global
Participants and Preferred Providers defined at the TIN/NPI level
Care Capitation (TCC) equal to 100% of total cost of care provided by Participant and Preferred Providers, and PCC
Geographic (proposed)
entities interested in taking on regional risk and entering into arrangements with clinicians in the region
between Full Financial Risk with FFS claims reconciliation and TCC
Lowest Risk Highest Risk
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coordination and management strategies prior to the first performance year (PY1). Model participants can also participate in other shared savings initiatives models such as the Medicare Shared Savings Program and Next Generation ACO Model, and other Innovation Center models.
Direct Contracting will be an Advanced Alternative Payment Model (APM). Model participants cannot participate in the Medicare Shared Savings Program or other shared savings initiatives.
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A Direct Contracting Entity (DCE) is an ACO-like organization, comprised of health care providers and suppliers, operating under a common legal structure, which enters into an arrangement with CMS and accepts financial accountability for the
aligned to the entity. DCEs that have experience serving Medicare FFS beneficiaries. Standard DCEs New Entrant DCEs High Needs Population DCEs DCEs that have not traditionally provided services to a Medicare FFS population. Beneficiaries are aligned primarily based on voluntary alignment. DCEs that serve Medicare FFS beneficiaries with complex needs employing care delivery strategies, such as those used by Program
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Direct Contracting Entity (DCE)
participate in the Model and contribute to the DCE’s goals pursuant to a written agreement with the DCE.
form relationships with two types
the DCE through their negotiated payment arrangement with the DCE, continue to submit claims to Medicare, and accept claims reduction
enhancements or patient engagement incentives
DC Participant Providers
to the DCE
DCE through their a negotiated payment arrangement with the DCE, continue to submit claims to Medicare, and accept claims reduction
enhancements and patient engagement incentives
Preferred Providers
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Model, introducing several new model design elements including:
benchmark stability, simplicity and prospectively; Capitation and other advanced payment alternatives for model participants; and Financial model that supports broader participation by entities new to Medicare Fee for Service and/or focused on delivering care for high needs populations.
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Direct Contracting will introduce several innovative methodologies to benchmark construction, including: MA Rate Book US Per Capita Cost (USPCC) Risk Adjustment
The DCE’s Performance Year Benchmark will incorporate an adjusted version of the Medicare Advantage Rate Book. The DCE’s Performance Year Benchmark will use the USPCC, developed annually by the Office of the Actuary (OACT), to establish the trend rate. The DCE’s Performance Year Benchmark will be adjusted to account for the risk of the population. CMS is exploring the possible application of a risk adjustment methodology that better addresses the costs experienced by complex and chronically ill populations.
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The Thesis
Having control of the flow of funds with their downstream providers and suppliers will enable DCEs to improve care coordination and delivery, and to better manage the health needs
resulting in reduced costs and better outcomes.
Direct Contracting offers DCEs several mechanisms to receive stable monthly payments.
Capitation Payment Mechanisms
DCEs receive a capitation payment covering total cost
care
cost
primary care services.
MANDATORY
Payment amount is NOT RECONCILED against actual claims expenditures.
Advanced Payment
DCEs that select Primary Care Capitation may receive an advanced payment of their FFS non-primary care claims.
VOLUNTARY
Payment amount is RECONCILED against actual claims expenditures Direct Contracting | Center for Medicare & Medicaid Innovation
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DCEs must select one of the two Capitation Payment Mechanisms. The Capitation Payment Mechanisms available vary based on the Risk Option selected.
Primary Care Capitation (PCC) Monthly capitation payments for primary care services furnished to aligned beneficiaries. Monthly capitation payments for all services furnished to aligned beneficiaries. Available for Global and Professional Total Care Capitation (TCC) Available for Global Only
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Timeline Implementation Period (IP) DCE Applicants Performance Period (PY1) DCE Applicants
November 25, 2019 – February 25, 2020 (Application tool available December 20, 2019 [tentative])
Application Period
March 2020 – May 2020
DCE Selection
April 2020 September 2020
Deadline for applicants to sign and return Participant Agreement (PA)
Late April 2020 (Implementation Period PA) December 2020 (Performance Period PA) December 2020
Initial Voluntary Alignment Outreach and start of IP or PY
May 2020 January 2021
This timeline may be subject to change. Please check the Directing Contracting webpage for webinar and office hour dates and times.
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Comprehensive ESRD Care (CEC) Model
2015 and will run through December 31, 2020.
(ACOs) formed by dialysis facilities, nephrologists, and other Medicare providers and suppliers work together with the goal to improve outcomes and reduce per capita expenditures for aligned ESRD beneficiaries.
for the Model showed lower spending relative to benchmark group and improvements
and quality measures. Kidney Care Choices (KCC) Model
will run through 2023 with the option for CMMI to extend the Model for one
responsible for patient’s care from CKD Stages 4,5 through dialysis, transplantation, or end of life care.
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Payment Options Overview Participants CMS Kidney Care First (KCF) Option Based on the Primary Care First (PCF) Model – nephrology practices will be eligible to receive bonus payments for effective management of beneficiaries Nephrologists/nephrology practices only Comprehensive Kidney Care Contracting (CKCC) Graduated Option Based on existing CEC Model One-Sided Risk Track – allowing certain participants to begin under a lower-reward
additional potential reward Must include nephrologists and nephrology practices; may also include transplant providers, dialysis facilities, and other kidney care providers on an optional basis CKCC Professional Option Based on the Professional Population-Based Payment option
services CKCC Global Option Based on the Global Population-Based Payment option of the Direct Contracting Model – with risk for 100% of the total cost
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CMS Kidney Care First (KCF) Practice Nephrologists Nephrology Practices Legal Entity & Contracting Requirements
under the model from CMS.
assume financial risk and make any required repayments to the Medicare program.
and ensuring compliance with program requirements, including but not limited to, reporting on quality measures.
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Kidney Contracting Entities (KCEs)
Nephrologists and Nephrology Practices Transplant Provider Dialysis Facilities (Optional) Other (Optional)
A KCE must include: at least one nephrologist or nephrology group practice, and at least one transplant center, transplant surgeon, transplant nephrologist, and/or organ procurement organization (OPO).
Kidney Care Choices | Center for Medicare & Medicaid Innovation
Legal Entity & Contracting Requirements
shared savings payments or payments received from CMS under the KCC model’s alternative payment mechanisms.
shared losses, if applicable.
mechanisms and ensuring KCC participant compliance with program requirements, including but not limited to reporting on quality measures.
guarantee, if applicable.
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Alignment for CKD Stage 4 & 5 and ESRD Beneficiaries
important one for beneficiaries with advanced CKD or ESRD.
CKD 4 or 5 with the same nephrologist who would then be treating them if they progress to ESRD.
Alignment for Transplant Beneficiaries
the KCE for three years from the month of transplant, while the transplant is viable.
beneficiary.
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participants to managed ESRD, based on the MCP
participants to manage CKD 4 / 5 patients
transplant
(available to CKCC option participants only)
QCP and AMCP based on participant’s year-over-year continuous improvement and performance relative to peers (available to KCF practices only)
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KCF includes: the Quality Gateway and the Performance Based Adjustment (PBA)
relative performance and continuous improvement on a set of quality measures covering utilization and safety
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KCEs have the choice of 3 CKCC options with increasing opportunity for risk
Graduated Risk Option Global PBP Option Professional PBP Risk Option
Description: KCEs will have
risk in the first PY and then graduate to downside risk in the subsequent PYs. This
based on the one- sided risk track in the CEC Model KCEs w ill share in 50% of shared savings
losses in the total cost
care for Part A and B services KCEs w ill be at ris k for 100% of the total cost
care for Part A and B services Risk Sharing: One sided, transitioning to two sided after 1
2 years 50% shared savings / losses 100% shared savings / losses Benchmark Discount: None None 3% for PY1 and PY2, increasing 1% each subsequent PY Eligible for Total Care Capitation: No No Yes Kidney Care Choices | Center for Medicare & Medicaid Innovation
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though financial accountability will not begin until 2021.
focus on building necessary care relationships and infrastructure.
More information will be available at The KCC Model Website. Sign up via email and follow CMS on Twitter (@CMSinnovates).
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The following table compares the three models discussed. See model websites for further detail.
Comprehensive Kidney Care Contracting Primary Care First Direct Contracting Kidney Care First
PCF-General Component: Primary care practices with advanced primary care capabilities prepared to accept increased financial risk in exchange for flexibility and potential rewards based on practice performance. SIP-Component: Practices that demonstrate relevant capabilities and care experience to accept SIP patients that CMS identifies in their service area who express interest in the model.
Eligibility
Each Direct Contracting Entity (DCE) must contract with DC Participant
Participant Providers may include, but are not limited to: physicians or
practitioners in group practice arrangements, networks of individual practices
physicians or
practitioners, and more. Nephrologists and nephrology practices who comply with additional eligibility criteria may apply to participate. Kidney Care Contracting Entities (KCEs) participating in the Comprehensive Kidney Care Contracting Options are required to include nephrologists or nephrology practices and transplant providers; while dialysis facilities and other providers and suppliers are optional participants in KCEs.
Application Deadline
January 22, 2020 February 25, 2020 January 22, 2020 January 22, 2020
Model Launch
January 2021 January 2021 Spring 2020 Spring 2020
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The following table compares the three models discussed. See model websites for further detail.
Primary Care First Direct Contracting Kidney Care First Comprehensive Kidney Care Contracting
Primary care practices can participate in one of three payment model options: 1) PCF-General Component; 2) Seriously Ill Population (SIP) Component; 3) Both PCF-General and SIP Components.
Payment
For more detail on the components of each model
Direct Contracting offers three options for participants to take on increasing levels of risk and potentially earn savings: 1) Professional (50% risk) 2) Global (100% risk) 3) Geographic (proposed full risk for a geographic population) In addition, participants will have choices related to capitated payments, cash flow, beneficiary alignment, and benefit enhancements. Participants will receive capitated payments for managing beneficiaries with late-stage CKD and ESRD, which will be adjusted based on quality performance and
will receive a bonus payment for every aligned beneficiary who receives a kidney transplant.1 The model offers three
increasing levels of risk and potential reward: 1) Graduated Option; 2) Professional Option; 3) Global Option.
1The full amount of the bonus payment will be paid out at set intervals provided the kidney transplant remains successful.
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For questions specific to your organization, please email: Primary Care First: PrimaryCareApply@telligen.com Direct Contracting: DPC@cms.hhs.gov Kidney Care Choices: KCF-CKCC-CMMI@cms.hhs.gov
Please submit questions via the Q&A pod on the right side of your screen.
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a) Application submission b) Participation requirements/eligibility c) Model payment structure and quality measures d) N/A; My
submitted our application and/or needs no more information
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Use the following resources to learn more about the Primary Care First, Direct Contracting, and Kidney Care Choices Models.
Primary Care First Direct Contracting Kidney Care Choices
CMS Innovation Center Listserv Primary Care First: PrimaryCareApply@telligen.com Direct Contracting: DPC@cms.hhs.gov Kidney Care Choices: KCF-CKCC-CMMI@cms.hhs.gov
Primary Care First RFA Direct Contracting RFA Kidney Care Choices RFA
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